Workplace training for senior trainees: a systematicreview and narrative synthesis of current approachesto promote patient safetyMerrilyn Walton,1 Reema Harrison,1 Annette Burgess,2 Kirsty Foster3

▸ Additional material ispublished online only. To viewplease visit the journal online(http://dx.doi.org/10.1136/postgradmedj-2014-133130).1School of Public Health,University of Sydney, Sydney,Australia2Central Clinical School,University of Sydney, Sydney,Australia3Northern Clinical School,University of Sydney, Sydney,Australia

Correspondence toDr Reema Harrison, School ofPublic Health, University ofSydney, Room 314 EdwardFord Building, Sydney,NSW 2006, Australia;reema.harrison@sydney.edu.au.

Received 9 November 2014Revised 20 April 2015Accepted 14 July 2015

To cite: Walton M,Harrison R, Burgess A, et al.Postgrad Med J PublishedOnline First: [please includeDay Month Year]doi:10.1136/postgradmedj-2014-133130

ABSTRACTBackground Preventable harm is one of the top sixhealth problems in the developed world. Developingpatient safety skills and knowledge among advancedtrainee doctors is critical. Clinical supervision is the mainform of training for advanced trainees. The use ofsupervision to develop patient safety competence hasnot been established.Objective To establish the use of clinical supervisionand other workplace training to develop non-technicalpatient safety competency in advanced trainee doctors.Data sources Keywords, synonyms and subjectheadings were used to search eight electronic databasesin addition to hand-searching of relevant journals up to1 March 2014.Method Titles and abstracts of retrieved publicationswere screened by two reviewers and checked by a third.Full-text articles were screened against the eligibilitycriteria. Data on design, methods and key findings wereextracted. Clinical supervision documents were assessedagainst components common to established patient safetyframeworks. Findings from the reviewed articles anddocument analysis were collated in a narrative synthesis.Results Clinical supervision is not identified as anavenue for embedding patient safety skills in theworkplace and is consequently not evaluated as a methodto teach trainees these skills. Workplace training in non-technical patient safety skills is limited, but one-offtraining courses are sometimes used.Conclusions Clinical supervision is the primary avenuefor learning in postgraduate medical education but themost overlooked in the context of patient safety learning.The widespread implementation of short courses is notmatched by evidence of rigorous evaluation. Supportingsupervisors to identify teaching moments duringsupervision and to give weight to non-technical skills andtechnical skills equally is critical.

INTRODUCTIONPreventable harm in hospitals due to healthcareactivities is one of the top six health problems inthe developed world.1 It also poses a significantproblem in developing countries; a recent recordreview study identified at least one adverse event in8.2% of hospital patients’ records.2 Preventableharm includes healthcare-associated infections,adverse drug events, wrong patients, wrong treat-ment and many other patient safety incidents; alloccur frequently.3–9

Healthcare has sought to learn from high-risk,high-reliability industries such as aviation.10

High-reliability organisations are often given creditfor their attention to non-technical skills training in

staff, which are defined as “the cognitive, social andpersonal resource skills that complement technicalskills, and contribute to safe and efficient task per-formance”.11 These include an array of cognitive andsocial skills but, in the context of preventable harm,often include decision-making, professionalism,interpersonal, leadership and team-working skills.12

Non-technical performance was recognised in USspecialist training when in 2007 the AccreditationCouncil for Graduate Medical Education (ACGME)published the following six core patient safety com-petencies: patient care; medical knowledge; interper-sonal and communication skills; professionalism;practice-based learning and improvement andsystems-based practice. These competencies form thefoundation of the latest ACGME accreditationprocess and closely link with those identified in the2005 Australian Patient Safety Education Frameworkand the 2005 CanMEDS Framework.13–15

Research on non-technical skills teaching haspredominantly focused on evaluating preclinicaleducation and training for doctors in postgraduateyears 1 and 2.16–19 While preclinical training in non-technical skills is essential, medical staff oftenexperience ‘cultural resistance’ to the adoption ofthese skills in practice.20 Once doctors have com-pleted internship and are accepted onto a specialtyprogramme, knowledge and skills are learnt mainlythrough clinical supervision. Clinical supervision isdefined as “the oversight—either direct or indirect—by a clinical supervisor of professional proceduresand/or processes performed by a student (trainee) ora group of students (trainees) within a clinical place-ment (term) for the purpose of guiding, providingfeedback on, and assessing personal, professionaland educational development in the context of eachlearner’s experience of providing safe, appropriateand high-quality patient care”.21

Medicine has complexity at all levels—organisa-tion, treatment and patient management. This com-plexity requires trainees to know and applyknowledge additional to their specific disciplineknowledge and expertise. Additional non-technicalskills and knowledge are required such as identify-ing, managing and preventing patient safety inci-dents; using evidence and information to enhancesafe practice; working safely (eg, effective team-work, engaging with patients, situational awareness,managing fatigue); being ethical (eg, being openand honest with patients about risks and mistakes);and communicating effectively with patients,carers and health professionals. Some patientsafety competencies exist under the umbrella ofprofessionalism or medical ethics but historically

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have been undervalued partly because of the dominant beliefsregarding the nature of scientific knowledge and the lack of‘objective’ evidence about learning from error and adverseevents.22 There is strong evidence showing that doctors whoknow how to apply patient safety skills and knowledge makefewer mistakes with less adverse outcomes for patients.23

Today, a patient safety mindset integrates ethical behaviour andprofessionalism with patient safety competencies, mainly inresponse to the increasing use of complex technology inhealthcare.

Situated learning is learning that takes place in the samecontext in which it is applied. Learning is considered a socialprocess whereby knowledge is co-constructed; therefore, learn-ing is situated in a specific context.24 Situated learning isimportant for trainee doctors because it provides them with theopportunity to learn skills and knowledge critical for safepatient care—competencies that can only be learnt in thecontext of the task.25 Trainees are likely to learn non-technicalskills such as effective teamwork and patient engagement byentering and participating in a community of practice, acquiringknowledge from observing and working with the healthcareteam, and more senior clinicians in particular.25 26 An essentialrole of a clinical supervisor is to assist their trainee to integrateclinical knowledge into practice—through demonstration, mod-elling and repetition. They, therefore, have a vital role inmaking non-technical patient safety skills and knowledge. Ifthese skills are not directly demonstrated during learning trai-nees will fail to see their relevance to safe patient care. Traineeswill learn these skills and knowledge through interactions withtheir clinical supervisor.26

The 2006 internationally endorsed Australian Patient SafetyEducation Framework describes the 22 competencies requiredby clinicians for safe healthcare and remains a foundation foridentifying non-technical skills required by clinicians in thecontext of enhancing patient care and reducing errors.12 Whileother frameworks exist, no others describe the underpinningknowledge, applied knowledge and the performance in relationto patient safety.27 28 The Australian Framework uniquely iden-tifies four levels of patient safety competence, while all healthprofessionals are responsible for patient safety, the knowledgeand performance required by each health professional is deter-mined by their degree of clinical and organisational responsibil-ity. In this way, the Framework sets out the skills and knowledgerequired by clinical supervisors who are identified as level 3(senior) healthcare workers.

In the recent past, the value of non-technical skills for saferpatient care has not intersected with the requirements for clin-ical supervision. Today, international recognition of the import-ance of these skills supports the need for a systematic review ofthe extent to which workplace training and supervision is usedto develop non-technical patient safety skills and knowledge inadvanced trainee doctors (see box 1). The non-technical skillsessential for reducing patient harm are those selected frompatient safety competencies described in Patient SafetyEducation Frameworks.12 27 28

OBJECTIVESThe study objectives were (a) to establish the extent to whichpatient safety (non-technical) skills and knowledge are includedin clinical and workplace supervision of doctors who are in aspecialty training programme, and (b) to identify other situatedmethods designed to transfer patient safety skills and knowledgeto doctors who are in a specialty training programme.

METHODSThe Preferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) statement is an evidence-basedapproach for conducting systematic reviews and meta-analyses.The PRISMA statement was used to guide the conduct of thissystematic review and there was no departure from this (seeonline supplementary appendix 1).30

Eligibility criteriaInclusion criteriaStudies were required to meet the following criteria to be eli-gible for inclusion: Population: included a sample of postgradu-ate year 3 or above (or equivalent internationally) advancedtrainees, the sample were enrolled in a specialty training pro-gramme and worked in a hospital or family medicine setting.Intervention: workplace training with the main focus on thosenon-technical skills associated with safe patient care.Comparator: another training strategy or no comparator.Outcome: learning of non-technical skills associated withpatient safety. Only studies that were published in English afterthe year 2000 and reported original primary data were eligible.

Exclusion criteriaStudies were excluded that did not meet the above criteria orwere letters, viewpoints, commentaries or editorials. Studies thatwere about developing tools/measures to assess non-technicalskills or about curricula were not eligible for inclusion.

In addition to the review, we conducted a document analysisof current guidelines for clinical supervisors including accredit-ation frameworks for advanced trainees. Government reports onclinical supervision were included in this analysis because of therecent efforts to improve clinical supervision as a way of redu-cing harm to patients.

Study search and identificationA range of text words, synonyms and subject headings for theconcepts of workplace training and supervision, non-technicalpatient safety skills and specialty trainees were developed (seeonline supplementary appendix 2) and used to undertake a sys-tematic search of electronic databases up to 1 March 2014(Medline; PubMed; Embase; PsychInfo; Web of Science; APIAS;Cochrane Library). The use of the term ‘Resident’ to describetrainees at a range of stages in North America required us toinclude this as a search term in order to capture these studies.We reviewed abstracts and full texts (where necessary) of studies

Box 1 Definition of trainee

In this review, an advanced trainee describes a trainee doctorthat is in postgraduate year 3 (PGY3) or above who is enrolledin a specialty training programme from one of the specialtiesidentified by the Medical Board of Australia as addictionmedicine; anaesthesia; dermatology; emergency medicine;general practice (family medicine); internal care medicine;medical administration; obstetrics and gynaecology;occupational and environmental medicine; ophthalmology;surgery; paediatrics and child health; pain medicine; palliativemedicine; pathology; physician; psychiatry; public healthmedicine; radiation oncology; rehabilitation medicine; sexualhealth medicine; sport and exercise medicine; surgery.29

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from North America that referred to ‘Residents’ to establish theexact year of level of trainee studied before determiningwhether the study was eligible. Hand-searching of relevant jour-nals and author contact were also used for completeness.Results were merged using reference management software(Endnote) and duplicates removed.

We supplemented the database search with a document ana-lysis of nine key clinical supervision guidelines, including cur-riculums for specialty training and assessment criteria foradvanced trainees. Key guidelines were identified by scoping thewebsites of the groups that are responsible for clinical supervi-sion in the Western world. We explored the extent to whichpatient safety (non-technical) skills were explicitly identifiedbecause the use of clinical supervision for this purpose may notbe fully captured in peer-reviewed journal articles. Documentsregarding trainees in the US, Canada, Australia and the UKhealth systems were included:▸ Health Workforce Australia: National Clinical Supervision

Support Framework.21

▸ Health Education and Training Institute Australia: The Superguide: A handbook for supervising doctors.31

▸ Oxford Deanery National Health Service UK: Handbook forClinical Supervisors.32

▸ Academy of the Specialty Training Board of (UK) RoyalColleges: Common Competencies Framework.33

▸ General Medical Council UK: Generic Curriculum forMedical Specialties.34

▸ ACGME: Common Program Requirements.35

▸ Royal College of Physicians and Surgeons of Canada: TheCanMEDS 2005 Framework.15

▸ Royal College of Physicians and Surgeons of Canada: TheCanMEDS 2015 Patient Safety and Quality ImprovementExpert Working Group Report.36

▸ The Royal Australasian College of Physicians: ProfessionalQualities Curriculum.37

Study selection and data extractionTwo authors (MW and RH) independently screened the titlesand abstracts for relevance, and articles that met the criteriawere obtained in complete form. These were then independ-ently examined against the criteria by two authors.Disagreements were resolved by consensus or consultation witha third person. The following data were then extracted fromeach publication: author(s), publication year, location, sample,setting, design, primary focus and main findings related to thetraining in non-technical patient safety competencies. A textualanalysis of the listed clinical supervision guidance guidelines wasconducted to assess how and where learning of non-technicalpatient safety competencies may occur. The competenciesincluded in three Patient Safety Frameworks were used as a setof criteria against which each document was assessed.13–15

Assessment of study qualityStudy quality was explored in the 13 publications. We did notassess study quality in the publication by Doherty et al becausealthough they assessed trainees’ performance these findings werenot reported and the effectiveness of the training strategy wasnot evaluated. The quality of studies was assessed using theQuality Assessment Tool for Studies with Diverse Designs.38

Criteria included the use of theory; appropriateness of studydesign and methods of data collection; stringency in reporting;sample size; outcome measures; analytic strategy and rigour;user involvement and critical analysis. Publications were scoredagainst the criteria on a four-point scale as to the extent to

which they included detail of each criterion (0=‘not at all’ to3=‘complete’). The total scores were used to give an indicationof the quality of each publication and the overall body of evi-dence. Two reviewers (RH and AB) assessed the 13 publicationsand substantial agreement (k=62.5%) was confirmed betweenreviewers. It was not appropriate to subject grey material relat-ing to clinical supervision to the quality assessment because thedocuments were not reporting research studies.

Narrative data synthesisPublications were heterogeneous and different outcomes wereassessed in each study; this meant study findings could not becompared quantitatively and a meta-analysis was prohibited.Although a meta-analysis is the gold standard for systematicreview synthesis, as a statistical synthesis, this approach can onlybe applied to quantitative data.39 Findings were thereforesynthesised in a narrative empirical synthesis around the studyobjectives. A narrative empirical synthesis is “an approach to thesystematic review and synthesis of findings from multiple studiesthat relies primarily on the use of words and text to summariseand explain the findings of the synthesis”.39

The narrative synthesis was undertaken in stages based on Popayet al.39 First, an initial description of the results of included studieswas developed, including an assessment of study quality. Due tothe small number of articles retrieved, studies were not weightedbased on the quality appraisal. Studies were preliminarily organisedto explore patterns in the data in terms of consistent findings; howand where learning of non-technical competencies occurs. Furtherinterrogation of the findings explored relationships between studycharacteristics and their findings, the findings of different studiesand the influence of the use of different outcome measures,methods and settings on the resulting data. Review findings weresynthesised with findings from the document analysis in thecontext of the review objectives.

RESULTSResults of the database searchAfter removing duplications, 995 records were identified. Titleand abstract screening identified 209 references that potentiallyfulfilled the inclusion criteria and copies of the full publicationswere sought. A total of 14 publications (13 unique data sets) ful-filled the eligibility criteria and were included in the review.Figure 1 shows the selection process.

Excluded studiesThe majority of the 197 excluded full-text publications (178)did not have a primary focus on the use of clinical supervisionor other workplace strategies to enable advanced trainees tolearn non-technical patient safety skills and knowledge.Fourteen publications were about curricula to enhance this typeof learning as opposed to workplace training and four furtherpublications were excluded due to the lack of patient safetyfocus; these papers often focused on the development of ethicsor management training. Four publications were excludedbecause they only included interns. One publication wasexcluded because the workplace training described washypothetical.

Characteristics of included studiesRelevant publications predominantly originated from the USA(8) but also from Holland (2), the UK (2), Australia (1) andIreland (1). Workplace training was provided either as part ofuniversity residency programmes (7), hospital-based pro-grammes for residents (4), federal agencies (2) or by a

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professional body (1). Participants were most often surgical trai-nees (6) or trainees from a variety of specialties (4), but therewere also programmes that targeted family medicine (2), anaes-thesia (1) or internal medicine trainees (1). Senior doctors wereoften responsible for teaching the trainees (9), but in some casesindependent providers (4) or independent researchers (1) wereleading the learning exercise(s). Publications were heterogeneousand included descriptions of training that were evaluated quanti-tatively (9), qualitatively (1), using mixed or multi-methods (4).We included one observational study and nine clinical supervi-sion guidelines from four countries (see online supplementaryfile for a summary of included studies).

Study qualityMany of the included studies rated highly on the descriptionsprovided of aims, objectives and the process of data collectionand analysis, but studies consistently lacked sufficient and repre-sentative samples. Most were evaluations of one-off courses thatemployed an opportunistic sample of trainees and authors didnot appear to consider the sample size to ensure that it was

adequate in terms of analysis. Inadequate sample sizes and diver-sity (particularly in gender and specialty) limits the generalisabil-ity of study findings. Included studies were also limited by thelack of user involvement in the design of the intervention andstudy; trainees were rarely reported as consulted in the develop-ment of courses and the strategies used to assess their effective-ness. The criteria against which each study and then the overallthe body of literature was considered are shown in box 2.

Learning of patient safety (non-technical) skills andknowledge in workplace supervisionThe degree to which learning of non-technical skills and knowl-edge occurs in clinical supervision is understudied. None of thematerial identified in the database searches used clinical supervi-sion as an avenue for workplace learning of non-technicalpatient safety competencies. Clinical supervision was used inone of the included publications but only as a strategy tosupport those who performed poorly in the main workplacetraining exercise.40

Analysis of the clinical supervision guidelines revealed thatacquisition of non-technical patient safety skills is consideredessential in specialist training programmes.15 35 37 Patient safetycompetence is an established aspect of workplace training thatfeatures in many competency frameworks. However, the extentto which clinical supervisors explicitly state and demonstratethese competencies is determined by the weight given to thiscomponent by supervisors. Table 1 demonstrates that almost allof the 22 competencies drawn from the patient safety frame-works are addressed in documents that describe specialty curric-ula (eg, the Academy of the Royal Colleges UK GenericCurriculum for Medical Specialties) or the required competen-cies for advanced trainees (eg, the Royal Australian College ofPhysicians Professional Qualities Curriculum).33 37 There is amultitude of guidelines that have been explicitly developed toaid clinical supervisors such as the National Clinical SupervisionFramework.21 This professionally or government-producedmaterial focuses on the way that clinical supervision shouldoccur; supervision structure; supervision style; the traits of goodsupervisors and the nature of the supervisor–trainee relation-ship. These documents generally lack detail regarding thecontent of clinical supervision. With the exception of theHandbook for Clinical Supervisors, the importance of clinicalsupervisors teaching or demonstrating non-technical patient

Figure 1 Flow chart of study selection process.

Box 2 Criteria study quality assessed against

Quality criteriaExplicit theoretical frameworkStatement of aims/objective in body of reportClear description of research settingEvidence of sample size considered in terms of analysisRepresentative sample of reasonable sizeDescription of procedure for data collectionRationale for choice of data collection toolDetailed recruitment data (no. approached, declined)Statistical assessment of reliability and validity of measurementtools (quantitative)Fit between study objectives and method of data collectionFit between study objectives and content of data collection toolFit between study objectives and method of analysisGood justification for method of analysisAssessment of reliability of analytic process (qualitative)Evidence of user involvement in design (eg, pilot work)Strengths and limitations critically discussed

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Table 1 Competencies addressed in documents reviewed

Guidance DocumentsNPSEF Competencies

National ClinicalSupervisionCompetencyResource21

The Super guide:A handbook forsupervising doctors31

Handbook forClinicalSupervisors32

Academy of the MedicalRoyal Colleges CommonCompetencies Framework 33

Federation of the RoyalColleges of Physicians:Generic Curriculum34

ACGME CommonProgramRequirements 35

CanMedsFramework200515

CanMEDS Patient Safetyand Quality ImprovementEWG Report36

RACP ProfessionalQualitiesCurriculum37

Communicating effectivelyInvolving patients aspartners

N N Y pg. 43 Y pg. 24 Y pg. 30 Y pg. 9 Y pg. 4 Y pg. 12 Y pg. 22

Communicating risk N N Y pg. 42 Y pg. 22 Y pg. 21 N Y pg. 3 Y pg. 5 Y pg. 21Open disclosure of AEs N N N Y pg. 54 Y pg. 36 Y pg. 9 N Y pg. 6 Y pg. 21

Obtaining consent N N Y pg. 40 Y pg. 68 Y pg. 27 N Y pg. 4 Y pg. 5 Y pg. 22Cultural awareness andrespect

N N Y pg. 32 Y pg. 11 Y pg. 15 Y pg. 9 Y pg. 4 Y pg. 5 Y pg. 35

Identifying, preventing and managing AEsRecognising/ reporting/managing AEs andnear misses

N N Y pg. 41 Y pg. 29 Y pg. 36 Y pg 10 N Y pg. 12 Y pg. 30

Managing risk N N Y pg. 41 Y pg. 30 Y pg. 21 Y pg 10 N Y pg. 9 Y pg. 31Understanding AEs andnear misses

N N Y pg. 41 Y pg. 28 Y pg. 36 Y pg. 10 N Y pg. 9 Y pg. 30

Managing complaints N N N Y pg. 54 Y pg. 36 N N N Y pg. 21Using evidence and information

Employing bestevidence-based practice

N N Y pg. 41 Y pg. 14 Y pg. 32 Y pg. 8 Y pg. 2 Y pg. 7 Y pg. 43

Using informationtechnology to enhancesafety

N N Y pg. 34 Y pg. 32 Y pg. 40 Y pg. 8 N Y pg. 9 Y pg. 27

Working safely

Being a team playerand leadership

N N Y pp. 36–37 and 44 Y pg. 32 Y pg. 22 Y pg. 9 Y pg. 5 Y pg. 13 Y pg. 28

Understanding humanfactors

N N N Y pg. 30 Y pg. 22 Y pg. 10 Y pg. 6 Y pg. 12 Y pg. 28

Understanding complexorganisations

N N Y pg. 41 Y pg. 35 N Y pg. 10 Y pg. 7 Y pg. 12 Y pg. 28

Providing continuity ofcare

N N Y pg. 35 Y pg. 32 Y pg. 22 Y pg. 10 N Y pg. 6 Y pg. 29

Managing fatigue andstress

N N N Y pg. 32 Y pg. 22 Y pg. 14 N Y pg. 8 Y pg. 28

Being ethical

Maintaining fitness topractice/work

N N N Y pg. 34 Y pg. 39 Y pg. 14 Y pg. 9 Y pg. 8 Y pg. 39

Professional and ethicalbehaviour

N N N Y pg. 87 Y pg. 39 Y pg. 9 Y pg. 10 Y pg. 8 Y pg. 38

Continuing learningBeing a workplacelearner

Y pg. 11 N Y pg. 41 Y pg. 80 Y pg. 31 Y pg. 8 Y pg. 9 Y pg. 7 Y pg. 32

Being a workplaceteacher

N N Y pg. 45 Y pg. 80 Y pg. 38 Y pg. 8–9 Y pg. 9 Y pg. 8 Y pg. 32

Specific issuesPreventing never events N N N N N N N N N

Medicating safely N N Y pg. 38 Y pg. 12 Y pg. 16 N N N Y 29

ACGME, Accreditation Council for Graduate Medical Education; AE, adverse event; EWG, Expert Working Group; NPSEF, National Patient Safety Education Framework; RACP, Royal Australasian College of Physicians.

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safety skills and knowledge to trainees (in addition to technicalskills) was not addressed nor promoted in guidance designed toaid supervision.32 Most of these documents indicate patientsafety is an outcome rather than a set of skills and knowledge tobe used.26

Other strategies for learning patient safety (non-technical)skills in the workplaceThe reviewed papers revealed that several strategies are cur-rently used to teach or demonstrate non-technical patient safetycompetencies to advanced trainees. Studies either targetedadvanced trainees specifically (5), included them as part of abroader group of medical or surgical trainees (8) or includedadvanced trainees among other health professionals (1).

Strategies usedWe identified that one-off courses or training exercises are themost common strategy used to teach non-technical patientsafety competencies (8).40–47 The duration of such courses was1–2 full work days for each cohort. Half of the papers reportedpilot one-off courses and presented the findings (4).40 41 45 46

Patient safety modules that made up part of a regular trainingprogramme (5) and naturally occurring learning moments (1)were also reported in the literature.48–53 Patient safety modulesoften took part over a series of 1 h sessions across the semesteror year. The content of one-off courses and patient safetymodules was similar; students received a proportion of didactictime with some coursework that involved application to theirclinical context.

Teaching methodsMultiple teaching methods were often combined (10).Combinations included face-to-face teaching (8), role-play (4),small or large group discussion (3), simulation (2), video train-ing or dramatisation (2), web-based teaching (1), chart reviewand/or case presentations (2), quality improvement projects (4)and workshops (1). Simulation was the sole teaching method inthree publications.40 45 47 The remaining study explored natur-ally occurring learning moments; researchers explored the useof ‘war stories’, in which senior medical staff used stories oftheir own experiences as avenues for learning non-technicalskills and knowledge (including those relating to safety) amongtrainees.50 None appeared to integrate patient safety competen-cies into clinical practice during the treatment of patients.

Evidence of effectivenessThere was limited evaluative work undertaken in relation to anyof the strategies reported. While 13 of the included publicationsconducted some form of evaluative work, in most cases this wasself-reported experiential data or feedback from participants.The lack of a comprehensive evaluation of each strategy prohib-ited our ability to establish whether any of the strategiesdescribed were effective.

Self-reported data demonstrated changes in attitudes towardssafety as a result of the workplace training, and in some cases, achange in safety behaviour including assertiveness in challenginga senior colleague.43 45 49 51 Whether the trainee put into prac-tice the assertiveness training knowledge was not investigated.Self-reported data also provided favourable appraisal of shortcourses as workplace training to develop non-technical patientsafety skills, particularly simulation training.40 41 43 47 51 Shortcourses promoted positive attitudes towards patient safety andmade participants feel that they had greater understanding ofpatient safety issues.40 41 Participants in one study

recommended that such courses are most beneficial in earlieryears of medical training.41

Patient safety modules integrated into medical training werealso positively evaluated through self-reported data.49 52 In onestudy, 65% of participants believed their experiences to be ‘edu-cationally important’ and that it prepared them to lead futurequality improvement projects.52 In another, participantsreported enhanced knowledge of quality improvement and thetraining promoted positive patient safety attitudes.49

Surgical complication rates and incident reporting ratesbefore and after each course were used as proxy indicators ofeffectiveness.42 44 Brannick et al42 reported a significant reduc-tion in the mean number of surgical complications from 26% to18% and errors from 18.5% to 13% following the course.Findings of Jansma et al44 revealed significant improvement inattitudes and intentions towards reporting following one of thecourses and at follow-up but no significant change in reportingbehaviour. For example, the proportion of participants whoconsidered the incident in the vignette worth reporting wentfrom 15% prior to the course to 43% post course. Singh et al46

reported that an Objective Structured Clinical Examinationdeveloped to assess error detection and disclosure skills was afeasible strategy, but that additional work to ensure the reliabil-ity and validity of each component is needed. None of the mea-sures employed in relation to any of the training strategiesdemonstrated evidence of a causal relationship between partici-pation and the outcome assessed.

DISCUSSIONOur analysis revealed the need for trainees to develop non-technical patient safety skills and knowledge during specialty train-ing is well established in specialty curricula and required compe-tencies.15 21 32–38 Situated learning that allows trainees to learnthrough participation and interaction with senior colleagues (suchas in clinical supervision) has been previously demonstrated to aidlearning.26 Yet our systematic review of research literature high-lighted that patient safety skills and knowledge are currently learntvia short courses in the workplace and modules within trainingprogrammes. There is no evidence from the included publicationsthat workplace learning of non-technical patient safety skillsoccurs ‘by the bedside’ and during clinical supervision.

There has been a rapid increase in the inclusion and evalu-ation of patient safety and quality improvement training in post-graduate medical curricula, but few studies explore workplacetraining strategies or the extent to which learning in postgradu-ate training translates into clinical practice.54 The widespreadimplementation of short courses to teach patient safety totrainees is not matched by evidence of rigorous evaluation.We have little knowledge of the extent to which trainees learnnon-technical skills and knowledge in short courses and,importantly, whether they apply this learning in practice.Although short courses appear to be popular with participants,learning non-technical competencies by the bedside may be aneffective strategy to embed patient safety principles in traineesthrough explicit role modelling.55 The use of standalonemodules or courses may also indicate to trainees that patientsafety competencies are an optional, and possibly less important,aspect of their role rather than a theme that runs throughoutevery aspect of clinical practice.55

Clinical supervision is the primary avenue for learning inpostgraduate medical education but the most overlooked in thecontext of patient safety learning; studies of supervision focuson theoretical models, availability, structure and content ofsupervision; skills and qualities of effective supervisors and their

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training and effective supervision strategies.56 Supervision pro-vides real-world opportunities for trainees to apply and developthe skills and knowledge learnt in preclinical medical education.Supervisors support trainees to enter into and participate in acommunity of practice with the healthcare team (including thepatient).57 In this way, supervision is a particularly suitablemethod for transferring and demonstrating non-technical com-petence in a dynamic learning environment.

Patient safety modules integrated into medical training arecommonly used and were positively evaluated in the includedstudies.49 52 Learning about patient safety in earlier years ofmedical training is considered beneficial for creating a safe andtransparent culture in healthcare.41 58 While integrating patientsafety into teaching in medical school is critical, patient safetymay be more visible in clinical practice than in the classroom.55

Because of the patients’ presence during clinical supervision, adiversity of teaching moments arise amidst care; trainees havean opportunity to apply their learning to react appropriately tonaturally occurring circumstances and the associated patient–practitioner interaction. Junior clinicians often experience diffi-culties applying their patient safety knowledge in the hierarch-ical healthcare workplace.58 More experienced healthprofessionals who have developed an understanding of thewider systems issues associated with unsafe care can more easilyapply their learning in the clinical environment.59 Learningpatient safety in the clinical environment is therefore moreappropriate for teaching advanced trainees how to use thepatient safety skills and knowledge taught in medical school.Such findings have led to the emergence of patient safetycourses for more practising clinicians.60

Non-technical patient safety competencies feature widely incompetency frameworks; clinical supervisors are required toinclude this learning.12 Yet the extent to which advanced trai-nees learn and practice these competencies in supervision islargely dependent on the value supervisors give to this aspect oftraining. In the context of applying discipline knowledge, clin-ical reasoning and decision-making to individual patients in acomplex working environment, senior doctors develop abroader set of non-technical skills that are critical to practisingsafely.26 Supervisors know how to recognise and respond tostress and fatigue, to manage work load effectively and to inter-act with patients and colleagues under a range of external pres-sures, but they do not always recognise the importance ofmaking this set of skills and knowledge explicit to trainees.26

Supervisors need assistance to identify the broader spectrum ofskills and knowledge that they can teach trainees during supervi-sion. Tools that help supervisors to identify learning opportun-ities in which they can explicitly demonstrate or discussnon-technical patient safety competencies are needed to assistsupervisors to give weight to non-technical skills and technicalskills equally during supervision.

Our findings must be considered with recognition of the lim-itations of both the reviewed papers and the method of review.Assessment of study quality indicated that despite a number ofstrong studies, the samples included were generally small andunrepresentative of the broader advanced trainee population,limiting generalisability of the findings. The evaluation of indi-vidual training programmes by the training provider (in manycases) may have presented a source of bias. It may be preferableto evaluate key components of workplace training to enhancepatient safety competence in larger-scale research rather than

evaluating individual courses. Despite accessing a broad range ofpublished material, the spread of this work means that somerelevant work (including that in unpublished material) may havebeen omitted due to the diversity of potential outlets for the dis-cussion of this topic, or variations in the terminology used todescribe this type of workplace training. Additionally, importantperspectives from the numerous editorial and commentarypieces or material produced by individual healthcare organisa-tions may also have been overlooked due to the exclusion ofnon-empirical work and the limited selection of guidance docu-ments. It is also possible that individual supervisors provideworkplace training around patient safety that is not explicitlyidentified in published work. Further work might seek to under-stand how commonplace and effective informal, opportunistictraining of this type might be for developing patient safety com-petence. A narrative synthesis was the most appropriate strategyto aggregate the data identified in this review where ameta-analysis was not possible, yet this approach is limited by alack of reproducibility, limited transparency and the wide varia-tions in the practice of this strategy.39

FORWARD VIEWClinical supervision is the primary avenue for learning in post-graduate medical education but the most overlooked in thecontext of patient safety learning. The widespread implementa-tion of short courses is not matched by evidence of rigorousevaluation. We have little knowledge of the extent to which trai-nees learn non-technical skills and knowledge in short coursesand, importantly, whether they apply this learning in practice.Trainees may learn to integrate patient safety knowledge andskills into their clinical work best when a supervisor demon-strates or discusses the importance of non-technical skills andknowledge. This type of situated learning offers a potential newapproach to the problem and deserves further rigorous study ina patient safety context.

Main messages

▸ Learning non-technical patient safety skills and knowledgeas an integrated part of medical training is critical.

▸ Non-technical patient safety skills and knowledge are notroutinely taught as part of clinical supervision.

▸ Clinical supervision is an opportunity to teach non-technicalpatient safety skills and knowledge using a situated learningapproach.

Current research questions

▸ How do clinical supervisors perspective their role in teachingnon-technical skills and knowledge to trainees?

▸ What teaching strategies are effective for clinical supervisorsto teach non-technical patient safety skills and knowledge totrainees?

▸ To what extent do trainees incorporate patient safety skillsand knowledge learnt in one-off courses into daily practice?

Walton M, et al. Postgrad Med J 2015;0:1–9. doi:10.1136/postgradmedj-2014-133130 7

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Key references

▸ Walton M, Barraclough B. Clinical supervisors: are they thekey to making care safer? BMJ Qual Saf 2013;22:609–12.

▸ Flin RH, O’Connor P, Crichton M. Safety at the sharp end: aguide to non-technical skills. Ashgate Publishing, 2008.

▸ Flin R, Patey R. Improving patient safety through training innon-technical skills. BMJ 2009;339:b3595.

▸ Kilminster SM, Jolly BC. Effective supervision in clinicalpractice settings: a literature review. Med Educ2000;34:827–40.

▸ Walton M, Jeffery H, Van Staalduinen S, et al When shouldstudents learn about ethics, professionalism and patientsafety? Clin Teach 2013;10:224–9.

Self assessment questions

1. Which of the following is not a type of preventable patientharm?A. Drug administered via incorrect routeB. Treatment given to the wrong patientC. Patient experiencing known side effects of a medication

2. What are non-technical skills?A. Cognitive, social and personal resource skillsB. Social and communication skillsC. Team-working skills

3. What is the most common way to teach trainees patientsafety skills and knowledge?A. Grand roundsB. Workplace seminarC. Standalone short course

4. Which of the following is a patient safety skill?A. Being ethicalB. Working effectively as part of a teamC. Both of the above

5. Which of the following do one-off patient safety coursesdemonstrate?A. Improved technical skillsB. Improved ethical behaviour in the workplaceC. Improved attitudes towards patient safety

Contributors Each of the listed authors made substantial contributions toconception and design, acquisition of data or analysis and interpretation of data;drafting the article or revising it critically for important intellectual content; and tothe final approval of the version to be published as set out in the UniformRequirements for Manuscripts Submitted to Biomedical Journals. MW conceived anddesigned the research idea. RH and AB were responsible for the acquisition of thepublications for review and interpretation of the included publications. All authorscontributed to the development of the review process and contributed to thedrafting the article or revising it critically and gave final approval for the versionsubmitted.

Funding The conduct of this review was supported by the School of Public HealthGrant Preparation Scheme at the University of Sydney.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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Answers

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